Level: Foundational
Difficulty: Easy
Subtopic: Macronutrients
NCLEX: A 63-year-old client with chronic kidney disease is being evaluated for nursing care related to macronutrients. A…
Nutrition Basic Care and Comfort
Case Study
A 63-year-old client with chronic kidney disease is being evaluated for nursing care related to macronutrients. Assessment data include the client has heart failure, 2+ edema, and a 2 kg weight gain in 24 hours. Which nursing action should the nurse take first?
Question
A. Implement the final step of the care plan before assessing the client.
B. Document the client as stable without reassessment.
C. Administer the next scheduled intervention before reassessing the client.
D. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
B. Document the client as stable without reassessment.
C. Administer the next scheduled intervention before reassessing the client.
D. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
Rationale
Correct answer: D. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
Rationale: First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.